Provider Demographics
NPI:1811937592
Name:CANTOR, JEROLD (CFNP)
Entity type:Individual
Prefix:
First Name:JEROLD
Middle Name:
Last Name:CANTOR
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N STILSON RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703
Mailing Address - Country:US
Mailing Address - Phone:208-344-7799
Mailing Address - Fax:208-344-7152
Practice Address - Street 1:801 N STILSON RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703
Practice Address - Country:US
Practice Address - Phone:208-344-7799
Practice Address - Fax:208-344-7152
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP158363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S70034Medicare UPIN
ID1342149Medicare PIN